Pneumonia

Topic Overview

What is pneumonia?

Pneumonia is a
lung infection that can make you very sick. You may cough, run a fever, and
have a hard time breathing. For most people, pneumonia can be treated at home.
It often clears up in 2 to 3 weeks. But older adults, babies, and people with
other diseases can become very ill. They may need to be in the hospital.

You can get pneumonia in your daily life, such as at school or work. This
is called community-associated pneumonia. You can also get it when you are in a
hospital or nursing home. This is called healthcare-associated pneumonia. It
may be more severe because you already are ill. This topic focuses on pneumonia
you get in your daily life.

What causes pneumonia?

Germs called bacteria or
viruses usually cause pneumonia.

Pneumonia usually starts when you
breathe the germs into your lungs. You may be more likely to get the disease
after having a cold or the
flu. These illnesses make it hard for your lungs to
fight infection, so it is easier to get pneumonia. Having a long-term, or
chronic, disease like
asthma, heart disease, cancer, or
diabetes also makes you more likely to get pneumonia.

What are the symptoms?

Symptoms of pneumonia
caused by bacteria usually come on quickly. They may include:

Cough. You will likely cough up
mucus (sputum) from your lungs. Mucus may be rusty or
green or tinged with blood.

Fever.

Fast breathing and
feeling short of breath.

Shaking and "teeth-chattering" chills.

Chest pain that
often feels worse when you cough or breathe in.

Fast
heartbeat.

Feeling very tired or very weak.

Nausea and vomiting.

Diarrhea.

When you have mild symptoms, your doctor may call this
"walking pneumonia."

Older adults may have different, fewer, or
milder symptoms. They may not have a fever. Or they may have a cough but not
bring up mucus. The main sign of pneumonia in older adults may be a change in
how well they think. Confusion or
delirium is common. Or, if they already have a lung
disease, that disease may get worse.

Symptoms caused by viruses
are the same as those caused by bacteria. But they may come on slowly and often
are not as obvious or as bad.

How is pneumonia diagnosed?

Your doctor will ask
you about your symptoms and do a physical exam. He or she may order a chest
X-ray and a
complete blood count (CBC). This is usually enough for your doctor to
know if you have pneumonia. You may need more tests if you have bad symptoms,
are an older adult, or have other health problems. In general, the sicker you
are, the more tests you may need.

Your doctor may also test mucus
from your lungs to find out if bacteria are causing your pneumonia. Finding out
what is causing your pneumonia can help your doctor choose the best treatment
for you.

How is it treated?

If pneumonia is caused by
bacteria, your doctor will give you antibiotics. These almost always cure
pneumonia caused by bacteria. Be sure to take the antibiotics exactly as instructed. Do not stop taking them just because you feel better. You need to take the full course of antibiotics.

Pneumonia can make you feel very sick. But
after you take antibiotics, you should start to feel much better. Call your
doctor if you do not start to feel better after 2 to 3 days of antibiotics.
Call your doctor right away if you feel worse.

There are things
you can do to feel better during your treatment. Get plenty of rest and sleep,
and drink lots of liquids. Do not smoke. If your cough keeps you awake at
night, talk to your doctor about using cough medicine.

You may
need to go to the hospital if you have bad symptoms, a weak
immune system, or another serious illness.

Pneumonia caused by a virus usually is not treated with antibiotics.
Sometimes, antibiotics may be used to prevent complications. But home
treatment, such as rest and taking care of your cough, usually is all that is
done.

How can you prevent pneumonia?

Experts recommend immunization for children and adults. Children get the pneumococcal vaccine as part of their routine shots. Two different types of pneumococcal vaccines are recommended for people ages 65 and older. If you smoke, or you have a long-term health problem, it's a good idea to get a
pneumococcal vaccine. It may not keep you from getting pneumonia. But if you do
get pneumonia, you probably won't be as sick. You can also get an influenza vaccine to prevent the flu, because sometimes people get pneumonia after having the flu.

You can also
lower your chances of getting pneumonia by staying away from people who have
a cold, measles, or chickenpox. You may get pneumonia after you have
one of these illnesses.
Wash your hands often. This helps prevent the spread of viruses and bacteria
that may cause pneumonia.

In people who have
impaired immune systems, pneumonia may be caused by
other organisms, including some forms of fungi, such as Pneumocystis jiroveci (formerly called Pneumocystis carinii). This fungus frequently causes
pneumonia in people who have AIDS. Some doctors may
suggest an
HIV test if they think that Pneumocystis jiroveci is causing the pneumonia.

How do you get pneumonia?

You may get pneumonia:

After you breathe infected air particles into your
lungs.

After you breathe certain bacteria from your nose and throat
into your lungs. This generally occurs during sleep.

If you breathe large amounts
of food, gastric juices from the stomach, or vomit into the lungs (aspiration pneumonia). This can happen when you have had a medical condition that
affects your ability to swallow, such as a
seizure or
a stroke.

A healthy person's nose and throat often contain bacteria
or viruses that cause pneumonia. Pneumonia can develop when these organisms
spread to your lungs while your lungs are more likely to be infected. Examples of times when this can happen are during or soon after a cold or if you have a long-term (chronic) illness, such
as
chronic obstructive pulmonary disease (COPD).

You can get pneumonia in your daily life, such as at school or work
(community-associated pneumonia) or when you are in a hospital or nursing home
(healthcare-associated pneumonia). Treatment may differ
in healthcare-associated pneumonia, because bacteria causing the infection in
hospitals may be different from those causing it in the community. This topic
focuses on community-associated pneumonia.

Symptoms

Bacterial pneumonia

Symptoms of
pneumonia caused by bacteria in otherwise healthy
people younger than 65 usually come on suddenly. They often start during or
after an
upper respiratory infection, such as the
flu or a cold. Symptoms may include:

Cough, often producing
mucus, also called sputum, from the lungs. Mucus may be rusty or
green or tinged with blood.

Fever, which may be less common in
older adults.

Shaking, "teeth-chattering" chills.

Fast, often shallow, breathing and the feeling of
being short of breath.

Chest wall pain that is often made worse by
coughing or breathing in.

Fast heartbeat.

Feeling very tired or weak.

Nausea and vomiting.

Diarrhea.

Nonbacterial pneumonia

Symptoms of pneumonia not caused by bacteria may come on gradually and are often not as bad or as obvious as symptoms of bacterial pneumonia. Many people don't know that they have
nonbacterial pneumonia, because they don't feel sick. But symptoms may include:

In older adults and children

Older adults may have
different, fewer, or milder symptoms, such as having no fever or having a cough with no mucus
(a dry or nonproductive cough). The major sign of pneumonia in older adults may
be a change in how clearly they think (confusion or
delirium) or when a lung disease they already have
gets worse.

In children, symptoms may depend on age:

In infants younger than 1 month of age,
symptoms may include having little or no energy (lethargy), feeding poorly,
grunting, or having a fever.

In children, symptoms of pneumonia are
often the same as in adults. Your doctor will look for signs such as cough and
a breathing rate over 60 breaths a minute.

Some conditions with symptoms similar to pneumonia include bronchitis,
COPD, and
tuberculosis.

What Happens

After you've been infected
with a pneumonia-causing organism, it takes as little as 1 to 3 days or as long
as 7 to 10 days for symptoms to appear. How severe
pneumonia is and how long it lasts depend on:

Your age and health. Older, sicker people
usually have more severe cases. And their cases of pneumonia are more likely to cause
complications, such as bacteria in the bloodstream
(bacteremia) or throughout the body (septicemia).

Whether bacteria
or a virus caused the pneumonia. Viral pneumonia usually is less severe than
bacterial pneumonia.

How quickly you treat it. The sooner you treat
pneumonia, the sooner symptoms go away.

Your
immune system. People who have
impaired immune systems are more likely to have more
severe pneumonia than people who have healthy immune systems.

In healthy people, pneumonia can be a mild illness that is
hardly noticed and clears up in 2 to 3 weeks. In older adults and in people
with other health problems, recovery may take 6 to 8 weeks or longer.

Going to the hospital

If you
have severe pneumonia, you may have to go to the hospital:

In most cases of pneumonia you get in your daily life, such as at
school or work (community-based pneumonia), it is not necessary to go to the
hospital.1

About one-third of people with
community-based pneumonia are age 65 or older.1 Older
adults are treated in the hospital more often and stay longer for the condition
than younger people.1 Pneumonia is more serious in
this group, because they often have and may develop other medical
problems.

Spreading pneumonia to others

If your pneumonia is caused by a virus or bacteria, you may
spread the infection to other people while you are contagious. How long you are
contagious depends on what is causing the pneumonia and whether you get
treatment. You may be contagious for several days to a week.

If you get
antibiotics, you usually cannot spread the infection to others after a day of
treatment.

What Increases Your Risk

You are more likely to get
pneumonia if you:

Smoke. Cigarette smoking is the strongest risk
factor for pneumonia in healthy young people.2

Have another medical condition, especially lung
diseases such as
chronic obstructive pulmonary disease (COPD) or
asthma.

Are younger than 1 year of age or
older than 65.

Have an
impaired immune system.

Take medicine called a proton pump inhibitor (such as
Prilosec or Protonix) that reduces the amount of stomach acid.3, 4

Drink excessive amounts of alcohol.

Recently had a cold or the
flu.

You are more likely to have
complications of pneumonia and need to go to the
hospital if you:

Are older than 65.

Have some other
illness (such as COPD,
diabetes, or asthma), or have gone to the hospital for a medical problem within the last 3 months.

Have had your spleen removed or
do not have a working
spleen (such as in
sickle cell disease).

Have an alcohol use problem.

Have a weak immune system.

Reside in a place where people live close together, such as a
college dorm or nursing home.

When To Call a Doctor

The faster you get treatment,
the faster you will get over
pneumonia. This is especially true for the very young,
for people older than 65, and for anyone with other long-lasting (chronic)
health problems, such as
asthma.

Have such bad
trouble breathing that you are worried you will not have the strength or
ability to keep breathing.

Cough up large amounts of
blood.

Feel that you may faint when you sit up or stand.

Call a doctor immediately if you
have:

A cough that produces blood-tinged or
rust-colored
mucus from the lungs.

A fever with shaking
chills.

Difficult, shallow, fast breathing with shortness of breath
or wheezing.

Call a doctor if your cough:

Frequently brings up yellow or green mucus from
the lungs and lasts longer than 2 days. Do not confuse mucus from your lungs
with mucus running down the back of your throat from your nasal passages
(postnasal drip). Postnasal drainage is not a worry.

Occurs with a
fever of 101°F (38.3°C) or
higher and brings up yellow or green mucus from the lungs (not postnasal
drainage).

Causes you to vomit a lot.

Continues longer
than 4 weeks.

Also call your doctor if you have new chest pain (more than
just discomfort when you cough) that gets worse with deep breathing and if you
have other symptoms of pneumonia, such as shortness of breath, cough, and
fever.

Watchful waiting

Watchful waiting is a wait-and-see approach. If
you get better on your own, you won't need treatment. If you get worse, you and
your doctor will decide what to do next.

You cough up
mucus that is running down the back of the throat from the
nasal passages (postnasal drip). But a cough in which the mucus is definitely
coming from the lungs rather than the nasal passages is a more serious problem,
and you should contact your doctor.

You have signs of the flu (high
fever, severe muscle aches or headache, and mild respiratory symptoms). For
more information, see the topic
Influenza.

Exams and Tests

A chest X-ray, which is almost always done to check for changes
in the lungs that may mean pneumonia and to look for other causes of your
symptoms. But an X-ray does not always show whether you have pneumonia,
especially if it is done when you first get sick. In some
cases, the X-ray results may:

Show
complications of pneumonia, such as infection of the heart muscle or the sac surrounding the heart.

Show
conditions that may occur with pneumonia, such as fluid in the chest cavity or
a collapsed lung.

Reveal another condition, such as
heart failure, lung cancer, or
acute bronchitis.

Lab tests for pneumonia

The need for more tests often depends on how severe
your symptoms are, your age, and your overall health. In general, the sicker
you are, the more tests you may need. This is especially true for older adults
and infants. One example of a test you may have is the arterial blood gas test.

Mucus test

If you are very ill, have severe shortness of breath, or
have a condition that increases your risk (such as
asthma or
COPD), your doctor
may test your mucus. Tests include a Gram stain and a sputum culture.

Rapid urine test

This test can identify some bacteria that cause pneumonia. This can help guide treatment for pneumonia.

HIV test

In people who have
impaired immune systems, pneumonia may be caused by
other organisms, including some forms of fungi, such as Pneumocystis jiroveci (formerly called Pneumocystis carinii). This fungus often causes
pneumonia in people who have AIDS. Some doctors may
suggest an
HIV test if they think that Pneumocystis jiroveci is causing the pneumonia.

Other lung tests

If you have severe pneumonia, you may need
other tests, including tests to check for
complications and to find out how well your
immune system is working.

Treatment Overview

Bacterial pneumonia

Doctors use
antibiotics to treat
pneumonia caused by bacteria, the most common cause of
the condition. Antibiotics have a high cure rate for pneumonia.5

Your doctor will
choose your antibiotic based on a number of things,
including your age, your symptoms and how severe they are, and whether you need
to go to the hospital. The number of days you take antibiotics depends on your general
health, how serious your pneumonia is, and the type of antibiotic you are
taking.

Most people see some
improvement in symptoms in 2 to 3 days. Unless you get worse during this time,
your doctor usually will not change your treatment for at least 3 days.

Getting started on antibiotics soon after getting pneumonia may help recovery.5

If
there is no improvement or if your symptoms get worse, you may need a
culture and a sensitivity test. These tests help
identify the organism that is causing your symptoms. These tests also help your
doctor find out whether the bacteria is
resistant to the antibiotic.

If you do not need to go to the
hospital for pneumonia, it is not usually necessary to identify the organism
causing the pneumonia before starting treatment. If you do go to the hospital,
you will probably have some testing to identify the bacteria.

Cannot care for yourself or would not be
able to tell anyone if your symptoms got worse.

Have severe illness
that reduces the amount of oxygen getting to your tissues.

Have chest pain
caused by inflammation of the lining of the lung (pleurisy) so
you are not able to cough up mucus effectively and clear your
lungs.

Are being treated outside a hospital and are not getting
better (such as your shortness of breath not improving).

Are not able to eat or keep food down, so you need to take fluids
through a vein (intravenous).

Viral pneumonia

Pneumonia also can be caused by
viruses, such as those that cause the
flu and
chickenpox (varicella). Antibiotics do not work to treat pneumonia caused by a virus.

People who are more likely to get pneumonia after having the flu (for example, pregnant women) may get an antiviral medicine such as oseltamivir (Tamiflu) or zanamivir (Relenza) to help relieve symptoms.

Varicella pneumonia, which is rare, also can be treated with
antiviral medicine.

What to think about

In most cases pneumonia is a short-term,
treatable illness. But frequent bouts of pneumonia can be a serious
complication of a long-term (chronic) illness, such as chronic obstructive
pulmonary disease (COPD). If you have a severe long-term illness, it may be
hard to treat your pneumonia, or you may choose not to treat it. You and
your doctor should discuss this. This discussion may include information about how to create an
advance directive.

The pneumococcal vaccine may not prevent pneumonia. But it can prevent some of the serious complications of pneumonia, such as
infection in the bloodstream (bacteremia) or throughout the body (septicemia),
in younger adults and those older than age 55 who have a healthy immune
system.6, 7

Other vaccines can prevent common diseases that sometimes lead to pneumonia, such as:

Measles. Vaccination of children for measles can
prevent most cases of measles. Adults may need to be vaccinated against measles
if they have not had the disease or were not vaccinated during
childhood.

Flu. A yearly flu vaccine may keep you from getting the flu. The flu often can lead to pneumonia, especially in
older adults or in people who have other long-term (chronic) diseases.
You can get the flu vaccine at the same time as the pneumococcal vaccine.

Chickenpox. The chickenpox shot (varicella-zoster vaccine) can prevent most cases of
pneumonia caused by the virus that causes chickenpox. Consider getting a
shot if you are older than 13 and have not had chickenpox.

Home Treatment

Home treatment is important for
recovery from
pneumonia. The following measures can help you recover
and avoid
complications:

Take care of your cough if it is making it hard
for you to rest. A cough is one way your body gets rid of the infection. And
you should not try to stop your coughing unless it is severe enough to make
breathing difficult, cause vomiting, or prevent rest.

Consider
taking
acetaminophen (such as Tylenol) or aspirin to help
reduce fever and make you feel more comfortable.
Do not give aspirin to anyone younger than 20 because
of the risk of
Reye syndrome. Be safe with medicines. Read and follow all instructions on the label.

Your doctor may want to see you after a week of treatment to make sure
you are getting better. Be sure to contact your doctor if you do not feel
better, your cough gets worse, you have shortness of breath or a fever, you
feel weak, or you feel faint when you stand up.

Cough and cold medicines

Be careful with cough and cold medicines. They may not be safe for young children or for people who have certain health problems, so check the label first. If you do use these medicines, always follow the directions about how much to use based on age and weight.

Always check to see if any over-the-counter cough or cold
medicines you are taking contain acetaminophen. If they do, make sure the
acetaminophen you are taking in your cold medicine plus any other
acetaminophen you may be taking is not higher than the daily recommended dose.
Ask your doctor or pharmacist how much you can take every day.

Medications

Doctors use antibiotics to treat pneumonia that is caused by bacteria. Although experts differ on their recommendations, the
first antibiotic used is usually one that kills a wide range of bacteria
(broad-spectrum antibiotic).8, 9 All antibiotics used have a high cure rate for
pneumonia.5

There are many types of antibiotics. Your doctor will decide which antibiotic will work best for you. In most cases, a doctor will
prescribe antibiotics without first identifying the exact organism causing the
illness.

If you don't get better with your first antibiotic, your doctor may add a second antibiotic to cover
other bacteria that are not being treated with the first
one. Or you may have more testing to identify the specific organism that is
causing the pneumonia.

Sometimes doctors use two antibiotics when first starting treatment.

What to think about

More and more bacteria are becoming resistant to certain antibiotics, making them less
effective. An example of this is MRSA, or methicillin-resistant Staphylococcus aureus, which is resistant to many types of
penicillin. To help fight antibiotic resistance, ask your doctor
how to take your antibiotics correctly, such as always finishing your
prescription.

Other Treatment

In most cases of
pneumonia in young, otherwise healthy people with
strong
immune systems, treatment can be done at home.
Antibiotics, rest, fluids, and home care are all that you need in order to
recover. But people who are having trouble breathing or have other lung
problems may need more treatment. Sometimes you may need
oxygen or medicines you breathe using an
inhaler or
nebulizer to help shortness of breath and wheezing
symptoms.

If home treatment does not help,
if symptoms get worse, or if signs of
complications of pneumonia develop, you may have to go
to the hospital. Hospital treatment for pneumonia may include:

Antibiotics given directly into the
bloodstream. A small needle is inserted into a vein (intravenous, or IV) to deliver the medicine.

Fluids given through a vein
(IV). They are given if you cannot drink liquids because of shortness of breath
or weakness.

Respiratory therapy, to remove mucus from the lungs.
This therapy may include deep breathing exercises,
postural drainage,
incentive spirometry, and chest physiotherapy, which involves
striking the chest with a cupped hand or applying a vibrating device to the
chest to loosen mucus. Chest physiotherapy is not needed in most cases. But
it may be helpful for people who have other lung conditions, such as
bronchiectasis.

Oxygen therapy. You
may need oxygen therapy if your doctor thinks that the cells of your body are
not getting enough oxygen. Oxygen can be given through a nasal tube or face
mask. For children, oxygen is often given using a tent that fits over the
crib.

Centers for Disease Control and Prevention (2010). Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23). MMWR, 59(34): 1102–1106. Also available online: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5934a3.htm?s_cid=mm5934a3_e.

Centers for Disease Control and Prevention (2010). Prevention of pneumococcal disease among infants and children: Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine - Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR, 59(RR-11): 1–18. Also available online: http://www.cdc.gov/mmwr/PDF/rr/rr5911.pdf.

McCabe C, et al. (2009). Guideline-concordant therapy and reduced mortality and length of stay in adults with community-acquired pneumonia: Playing by the rules. Archives of Internal Medicine, 169(16): 1525–1531.

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